Financial Barriers to the Optimal Use of Peritoneal Dialysis in France and Europe, as in the United States
Authors: Guy Rostoker, Belkacem Issad
Journal: Journal of the American Society of Nephrology (2022)

We read with great interest the article of Baerman et al. on the Cost Barriers to More Widespread Use of Peritoneal Dialysis in the United States where the authors describe in depth the current financial limitations to the more widespread use of peritoneal dialysis (PD) and potential new economic incentives to overcome this in the United States.1 Despite differences in the social coverage of healthcare costs between the United States and the European Union, the same barriers seem to exist for optimal use of PD, namely poor and biased information for patients on home dialysis techniques, inadequate training of nephrologists on PD, and a lack of strong financial incentives for patients, doctors, and healthcare providers.2 Although survival with PD is identical to that with hemodialysis (HD), PD is associated with more autonomy, a better quality of life, and a decreased risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.2 Despite these advantages, PD is still underused. Although home dialysis is carried out by 25% of patients with ESKD in Sweden and 21% in the Netherlands, it is barely used in France, where it currently concerns only 7% of dialysis patients (6% on PD and 1% on home HD).2 Similarly, low figures for home dialysis have also been reported in Germany (6%) and Portugal (7%).2 We recently analyzed the cost of home dialysis in France in comparison with in-center HD and found a monthly cost of approximately 6100 USD for in-center HD versus 4800 USD for self-performed automated PD (APD) and 4100 USD for self-performed classic PD (CAPD).3 If a patient aged 70–80 years (currently, most are referred to HD centers) could be taught to become autonomous (individually or as a couple), the net gain for the payer in France would be approximately 1300 USD per month for self-performed APD and 2000 USD per month for self-performed CAPD. In order to encourage the development of self-performed PD, the precepts of Baerman et al. could be applied to France as follows: 70% of these savings would be retained by the national social insurance and the remaining 30% could be redistributed equally among healthcare institutions, physicians, and patients (i.e., between 130 and 200 USD per month per patient), corresponding to nearly double the medical fees for monitoring and for each patient’s compensatory assistance package (autonomy package), combined with a generous increase in the institutional packages of 4.1% for APD and 7.9% for CAPD.3 Disclosures G. Rostoker reports consultancy fees from Astellas (board on roxadustat, 2019–2021), GlaxoSmithKline (board on daprodustat, 2022), Vifor (board on difelikefalin, 2021–2022); reports research funding for scientific presentations from Amgen, Astellas, Baxter, Hemotech, Gambro Hospal, Nipro, Physidia, and Theradial; reports honoraria from Amgen, Astellas, GlaxoSmithKline, Roche, Sanofi, and Vifor; and is on the speakers bureau for Astellas and Baxter. The remaining author has nothing to disclose. Funding None.